Implications of Repeal of the ACA for American Fertility

By June Carbone | January 27, 2017

In considering the potential impact of the repeal of the Affordable Care Act, efforts to defund Planned Parenthood, and other actions that may affect women’s health, most of the discussion has appropriately been on the impact on individual women. Indeed, Texas demonstrates the risks. The state had operated a Medicaid financed family planning system that included funds for Planned Parenthood. In 2011, the state legislation cut family planning grants by 66%, and tried to redirect federal funds from Planned Parenthood to more general county-based programs. Although litigation initially prevented the switch, Texas eventually succeeded in replacing the federal funds with state money, and moving such funding away from family planning providers.

Less examined is the potential impact on overall American fertility. The United States is unusual among developed nations both in its high birth rate and its correspondingly high rate of unintended pregnancies. Until the Great Recession, overall American fertility had been at 2.1, that is, an average of 2.1 children per woman, just above replacement levels. Since the Great Recession, however, that rate has fallen to 1.86, a rate that resembles Northern Europe. The potential implications are complex and potentially far-reaching. On the one hand, lower overall fertility, particularly in developed countries, can lead to lower economic growth. On the other hand, if the decline comes primarily from fewer unplanned births, it can lead to greater investment in children, and a narrowing of class-based disparities in the timing and number of children. The decline in unplanned pregnancies also tends to increase women’s autonomy and to reduce the incidence and importance of abortion.

Three big stories underlie the change in overall fertility. First, is the bifurcated nature of American fertility. Between 1990 and 2008, the best off Americans saw their unintended pregnancy rates fall by half, while they increased substantially for poorer women; those trends reversed after 2008. Second, the effect has been particularly marked among Latinas. They have had the higher fertility rates than any other segment of the American population leading into the Great Recession. Since 2008, however, Latina fertility, particularly in what had been the peak childbearing years between the late teens and early twenties has fallen off a cliff, explaining half of the overall American fertility drop. Third, the consensus among the few studies to date is that the increased efficacy of contraception has played an important role in the drop in fertility. While rigorous studies have yet to be undertaken, the evidence suggests that increased access through the Affordable Care Act, which mandates contraceptive coverage as part of private health insurance coverage and expands access through Medicaid, is an important part of the explanation.

Conclusion

Overall, greater use of contraception accounts for a large portion of the drops in unintended pregnancy, though individual state rates continue to vary substantially. The Guttmacher Institute concludes that both more use of contraception and greater use of more effective forms of contraception contribute to the changes; Pew, looking at just teen births, attributes a greater role to more effective forms of contraception. The most effective forms of contraception require a prescription and can be expensive. ACA mandates for their coverage make them accessible to a larger group of women, and Guttmacher ties at least some of the regional variations to insurance and Medicaid coverage. The declines in unplanned pregnancies have had beneficial effects on families, including increasing the percentage of births within marriage for the first time in decades and reducing the percentage of births to teens. Changes to the ACA mandate may reverse the recent trends, which have finally seen poorer women adopt some of the techniques that have long been available to better off women.

— June Carbone, Professor and Robina Chair in Law, Science and Technology, University of Minnesota, School of Law